1 5 Running head: ASSIGNMENT TITLE HERE Literature Synthesis Literature Synthesis Advance-Get Answer Now
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Advance care planning (ACP) involves numerous clinical behaviors and processes associated with documentation and evaluations; yet, it remains suboptimal among cancer patients across the healthcare industry. Primary challenges in most clinical settings include inadequate training, minimal available time, and lack of experience to perform ACP. This research examines if implementing an ACP online site, “PREPARE for Your Care,” with a readable advance directive will enhance documentation rates of cancer patients in a New York Cancer Center within eight weeks. PREPARE is an interactive and evidence-related site that utilizes videos for promoting behavior change practices towards improved advance directives (AD). Main behavior change elements include decision-making, knowledge development, readiness, and self-efficacy. Most studies concentrate on advance directive implementation. Thus, this research seeks to bridge the gap by identifying the impacts of engaging ACP based on online tools and understandable directives among end-of-life patients. Integrating the PREPARE clinical tool plus readable advance directives can enhance ACP practices among oncology patients within primary care settings across the United States.
In adult cancer patients, would the translation of research conducted by Lume et al. on the implementation of PREPARE For Your Care online clinical tool used in conjunction with current practice utilizing the easy-to-read advance directive increase the number of completed advance directives in an urban New York Cancer Center within eight weeks?
This research employs a comprehensive systematic review of recent studies associated with integrating an understandable directive in conjunction with the PREPARE clinical tool to develop positive clinical behaviors for improved documentation. Various databases employed in this study include Cochrane and PubMed for identifying the English Language published articles in the past five years. The articles are peer-reviewed and full text to outline common themes and illustrations associated with the healthcare sector’s advance care planning and directives. Established limitations include limited generalizability, diminished time for investigation, and lack of complete responses from specific study populations. Nevertheless, this systematic review produces significant views regarding the impacts of ACP and advanced directives on end-of-life discussions and documentation.
The illustrated articles focus on the need for advanced care planning across Acute Care settings through easy-to-read advance directives and the PREPARE online clinical tool. In the first article, Sudore et al. (2018) aim to compare the effectiveness of integrating PREPARE in conjunction with a comprehendible directive with a standalone directive to improve patient-centered interaction and documentation. The article employs a randomized clinical trial across San Francisco’s primary care centers from February 2014 to November 2017. Clinical subjects comprised a total of 986 English or Spanish-based care patients with two or more severe conditions and 55 years or older. According to Sudore et al. (2018), the PREPARE clinical tool led to increased rates of ACP documentation than the standalone advance directive. The article supports this intervention by indicating the need for combining an evidence-based PREPARE program with a proper directive to promote enhanced patient-centered engagement and documentation across English and Spanish-based groups.
Lum et al. (2018) sought to compare the outcomes of the PREPARE clinical tool in accordance with a readable AD with a basic AD based on clinical behavior changes regarding documentation. This article also employs a qualitative survey among San Francisco’s primary care patients in SFVA. Lum et al. (2018) conducted the investigation from 2013 to 2015 on SFVA English patients of around 60 years old, reportedly with at least two chronic illnesses. The authors indicated improved behavior change actions, such as decision-making and knowledge development on the PREPARE, than the basic AD. This article contributes to the current research by comprehensively identifying the impacts of PREPARE plus AD on critical changes in clinical practice.
The third article is a randomized investigation, which similarly seeks to examine the varying impacts of the PREPARE clinical tool and an integrated easy-to-read AD with an exclusive AD. Nouri et al. (2021) investigated San Francisco’s primary care settings, with 986 subjects reported with two or more serious medical conditions. The mean age of the participants was 63 years and distributed across English- and Spanish- populations. According to the researchers, the PREPARE program indicated more incredible ACP documentation than the exclusive AD among patients diagnosed with cancer and those without cancer. The article contributes to this intervention by establishing how PREPARE can alleviate ACP disparities among primary care patients.
A qualitative study by Miller et al. (2019) sought to establish the influence of an ACP intervention focused on managing standard challenges encountered across the nursing practice. According to the authors, the primary issues associated with low performance regarding ACP include inadequate training, confidence, and time among care providers. The researchers conducted interviews with Australian patients between 2014 and 2015 to determine their views regarding ACP interventions to address challenges in the nursing practice. The article contributed to this intervention based on six critical elements associated with general practice nurses-facilitated ACP: ideas evaluations, therapeutic clinical engagements, diminished family burden, independent decision-making, enhanced family communication, and relevance of making requests.
In the article by Bernard et al. (2020), a cross-sectional investigation founded on a self-administered questionnaire aims to evaluate the challenges encountered by older patients concerning communicating to clinical practitioners and family members about ACP. The researchers distributed the questionnaire across 20 family practice settings in 3 Canadian provinces. The respondents developed various themes associated with ACP challenges, including failure of MD to bring up the topic, lack of adequate knowledge, and diminished appointment times. The article supports this intervention by proposing the integration of patient education towards improving patient-practitioner relationships.
Discussion among patients, family members, and clinical practitioners regarding end-of-life aspects remains difficult across major organizations. As such, Iglesias et al. (2020) employ a mixed-method research to determine the efficacy of a Go Wish clinical tool and the function of defense techniques in the discussion of life-threatening conditions between key stakeholders. Iglesias et al. (2020) combined a randomized trial with a qualitative study to determine end-of-life communications’ cognitive and psychological elements. The study sufficiently contributes to the Picot question by identifying the benefits of implementing patient-based interventions to elevate written Ads among early-stage palliative outpatients.
Consequently, clinical settings avoid ACP discussions due to associated mental distress among patients with life-threatening illnesses. Green et al. (2015) conducted a randomized assessment to examine the impacts of the “Making Your Wishes Known” (MYWK) online tool with ACP-only concerning ACP engagements. The authors hypothesize that an online decision assistance mechanism (MYWK) would enhance knowledge development and self-efficacy without adversely affecting patient hope and anxiety. In this view, the article promotes this intervention by pointing out the need to understand patients’ feelings and perspectives during ACP discussions.
Furthermore, numerous barriers are encountered during ACP engagement across all clinical levels during end-of-life interventions. According to clinical practitioners, Howard et al. (2018) employ a cross-sectional survey to examine common barriers and enablers of ACP in primary care. Study subjects comprise 117 family physicians and 64 clinical professionals in Canada across Ontario, Alberta, and British Columbia. Major concerns cited by physicians include diminished patient engagements and lack of electronic transfer of ACP across hospitals, while clinical professionals pointed to minimal knowledge and challenges accessing physicians. In this view, this research develops potential barriers that can occur when discussing end-of-life ACP.
Currently, there are minimal ACP standards that consider patient perspectives and values in oncologic care. Epstein et al. (2018) integrate a randomized trial to assess the clinical benefits of a clinical-based ACP intervention for patients with advanced cancer. The study incorporated 33 subjects to measure the viability of the P-COCC tool. Thirty-two participants reported the importance of utilizing P-COCC rather than usual care mechanisms to promote positive clinical outcomes. This article contributes to the intervention by identifying the need to consider patient wellbeing in terms of anxiety and distress during end-of-life discussions.
Oklahoma clinical centers report less than 10 percent AD completion rate. Wickersham et al. (2019) incorporate a qualitative randomized trial to determine the most influential advance directive for clinical practice. The authors conducted interviews with patients and practitioners across six primary care settings to assess their perspectives towards integrating the OKAD and the Five Wishes form. Clinicians and patients preferred Five Wishes over OKAD due to its easy-to-read, usability, and understandable aspects. Therefore, the article promotes the implementation of more effective tools for capturing end-of-life patient preferences with respect to this research.
Similarly, Atherton (2020) employs a randomized assessment to evaluate the applicability of Project Give Wishes for ACP in primary care practices. The research sought to manage the issue of documentation through the current standard ADs in a Northern Arizona primary care setting. Based on a 16-week study, the Five Wishes tool improved AD completion by 25.4 percent by eliminating common ACP challenges. Thus, Project Five Wishes identified the need for evidence practices to facilitate change for effective engagement of crucial healthcare stakeholders.
It is important to promote participation and comprehension in the ACP practice among rural members for effective decision-making. Splendore and Grant (2017) assessed the feasibility of implementing a nursing-based Five Wishes program in a community using questionnaires. A pre-post repeated measures design was conducted across a reliable sample of rural residents of individuals above 18 years in various states. The authors reported the acceptability and effectiveness of the Five Wishes program across communities, which support this research proposal.
End-of-life discussions, especially with the younger generation, are challenging. Wiener et al. (2008) employed a qualitative survey to determine if the youth population with life-threatening conditions prefers documenting their preferences concerning care provision. In this case, the Five Wishes program is also tested to evaluate its feasibility to collect personal viewpoints. 95 percent of the respondents reported favorable outcomes with the integration of ACP tools such as Five Wishes to honor the wishes of the younger generation. This article contributes to this proposal by illustrating the importance of upholding patient perspectives regardless of age.
Furthermore, family-based ACP for young oncology patients is crucial for promoting universal wellbeing. Lyon et al. (2013) employ a randomized investigation to determine the importance of acknowledging family viewpoints regarding treatment choices among adolescents. The research established that most young individuals preferred various ACP tools such as Five Wishes to document their wishes. The article shows the need for considering family perspectives regarding clinical approaches among youth diagnosed with cancer.
Finally, ACP is crucial for improved palliative care among individuals who have dementia due to life-threatening illnesses. Vandervoort et al. (2014) integrated a cross-sectional assessment to determine the quality of 101 deaths within nursing homes associated with ACP practices. According to the authors, there is a significant link between a written ACP and improved quality of death among residents with dementia. In this view, the research supports this intervention by identifying the importance of early engagement with individuals with dementia across nursing homes to uphold their final requests and minimize stress levels.
Comparison of Articles
There are numerous similarities and differences identified across the analyzed articles. Common themes identified across the literature review encompass ACP tools for enhancing clinical discussions and documentations, end-of-life engagements between key healthcare stakeholders (patients, practitioners, and family members), the need for completed advanced directives across all populations with life-threatening conditions, and the importance of eliminating common challenges to ACP across primary care settings. In terms of methods, most articles employ randomized clinical trials to investigate the efficacy of advanced ACP tools such as PREPARE, Five Wishes, Go Wish, and written ADs. On the other hand, various articles employ qualitative surveys and cross-sectional methods to explore clinical perspectives regarding ACP interventions, particularly for end-of-life practices. The main limitation encountered by most studies involves time restrictions to obtain significant information comprehensively. Nevertheless, the literature review conclusively identifies the need for enhancing ACP practices for end-of-life patients to ensure that clinicians and health professionals consider their wishes and preferences during an intervention.
Recommendations for Future Research
Identified gaps in the research involve the high concentration of a majority of studies on AD completion across primary care settings. Consequently, most studies entail restrictive generalizability due to focusing on clinical studies in specific regions. This gap could lead to a lack of comprehensive data that reflects a vast population. Researchers did not access adequate responses from all recruited participants in other investigations due to certain challenges such as fatigue and diminished clarification of ideas. Lack of sufficient time for implementation also negatively affects the reliability of key findings. As such, it is recommended that future research considers evaluating data from diverse populations and regions to develop inclusive and general conclusions regarding ACP interventions.
The literature review was successful and informative. The researcher gained crucial insights regarding the importance of ACP tools and readable advanced directives across primary care settings in the United States. Most examined articles incorporate cross-sectional studies, qualitative surveys, and randomized clinical trials to compare the impacts of ACP techniques such as PREPARE and Five Wishes with AD-only regarding end-of-life discussions and documentations. According to multiple researchers, online planning tools and written advance directives portray positive clinical outcomes and engagements. Furthermore, ACP interventions assist in eliminating common barriers to patient-practitioner solid relationships in the healthcare sector. In conjunction with an easy-to-read AD, clinical tools such as PREPARE facilitate documentation and discussions regarding life-threatening conditions. Furthermore, involving nurses in ACP can positively impact patients since they effectively understand their wishes and preferences to minimize health burdens. Therefore, advanced ACP tools are recommended to enable practitioners to comprehend patients’ psychological and cognitive processes when confronted with end-of-life discussions.
Atherton K. N. (2020). Project Five Wishes: promoting advance directives in primary care. Journal of the American Association of Nurse Practitioners, 32(10), 689–695. https://doi.org/10.1097/JXX.0000000000000289
Bernard, C., Tan, A., Slaven, M. et al. (2020) Exploring patient-reported barriers to advance care planning in family practice. BMC Fam Practice 21, 94. https://doi.org/10.1186/s12875-020-01167-0
Epstein, A. S., OReill, E. M., Shuk, E., Romano, D., Li, Y., Breitbart, W., & Volandes, A. E. (2018, August). A randomized trial of acceptability and effects of values- based advance care planning in outpatient oncology: Person-centered oncologic care and choices. Advance Care Planning in Oncology, 56(2), 169-177. http://dx.doi.org/10.1016/j.jpainsymman.2018.04.009
Iglesias K, Busnel C, Dufour F, et al. (2020) Nurse-led patient-centered intervention to increase written advance directives for outpatients in early-stage palliative care: study protocol for a randomized controlled trial with an embedded explanatory qualitative study BMJ Open 2020;10:e037144. https://doi.org/10.1136/bmjopen-2020-037144
Green, M. J., Schubart, J. R., Whitehead, M. M., Farace, E., Lehman, E., & Levi, B. H. (2015). Advance Care Planning Does Not Adversely Affect Hope or Anxiety Among Patients With Advanced Cancer. Journal of Pain and Symptom Management, 49(6), 1088-1096. https://doi.org/10.1016/j.jpainsymman.2014.11.293
Howard, M. (2018, April). Barriers to and enablers of advance care planning with patients in primary care. Canadian Family Physician, 64(4), e190-e198. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5897087/
Lum, H. D., Barnes, D. E., Katen, M. T., Shi, Y., Boscardin, J., &Sudore, R. L. (2018). Improving a Full Range of Advance Care Planning Behavior Change and Action Domains: The PREPARE Randomized Trial. Journal of pain and symptom management, 56(4), 575–581.e7. https://doi.org/10.1016/j.jpainsymman.2018.06.007
Lyon, M. E., Jacobs, S., Briggs, L., Cheng, Y. I., & Wang, J. (2013). Family-centered advance care planning for teens with cancer. JAMA pediatrics, 167(5), 460–467. https://doi.org/10.1001/jamapediatrics.2013.943
Miller, H., Tan, J., Clayton, J. M., Meller, A., Hermiz, O., Zwar, N., & Rhee, J. (2019). Patient experiences of nurse-facilitated advance care planning in a general practice setting: A qualitative study. BMC Palliative Care, 18(25), 1-8. https://doi.org/10.1186/s12904-019-0411-z
Nouri, S. S., Barnes, D. E., Shi, Y., Volow, A. M., Shirsat, N., Kinderman, A. L., Harris, H. A., &Sudore, R. L. (2021). The PREPARE for Your Care program increases advance care planning engagement among diverse older adults with cancer. Cancer, 127(19), 3631–3639. https://doi.org/10.1002/cncr.33676
Splendore, E., & Grant, C. (2017). A nurse practitioner-led community workshop: Increasing adult participation in advance care planning. Journal of the American Association of Nurse Practitioners, 29(9), 535–542. https://doi.org/10.1002/2327-6924.12467
Sudore, R. L., Schillenger, D., Katen, M. T., Shi, Y., Boscardin, J., Osua, S., & Barnes, D. E. (2018). Engaging diverse English- and Spanish-speaking older adults in advance care planning: The PREPARE randomized clinical trial. JAMA Internal Medicine, 178(12), 1616-1625. https:// doi:10.1001/jamainternmed.2018.4657
Vandervoort, A., Houttekier, D., Stichele, R. V., Van der Steen, J. T., & Van den Block, L. (2014, March 10). Quality of dying in nursing home residents dying with dementia: does advance care planning matter? A nationwide postmortem study. PLoS ONE, 9(3). http://dx.doi.org/10.1371/journal.pone.0091130
Wickersham, E., Gowan, M., Deen, M., &Nagykaldi, Z. (2019). Improving the adoption of advance directives in primary care practices. Journal of the American Board of Family Medicine, 32(2) 168-179. https://doi.org/10.3122/jabfm.2019.02.180236
Wiener, L., Ballard, E., Brennan, T., Battles, H., Martinez, P., & Pao, M. (2008). How I wish to be remembered: the use of an advance care planning document in adolescent and young adult populations. Journal of palliative medicine, 11(10), 1309–1313. https://doi.org/10.1089/jpm.2008.0126
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